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Monnelly V, Josephsen JB, Isayama T, de Almeida MFB, Guinsburg R, Schmölzer GM, Rabi Y, Wyckoff MH, Weiner G, Liley HG, Solevåg AL. Exhaled CO 2 monitoring to guide non-invasive ventilation at birth: a systematic review. Arch Dis Child Fetal Neonatal Ed 2023; 109:74-80. [PMID: 37558397 DOI: 10.1136/archdischild-2023-325698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE Measuring exhaled carbon dioxide (ECO2) during non-invasive ventilation at birth may provide information about lung aeration. However, the International Liaison Committee on Resuscitation (ILCOR) only recommends ECO2 detection for confirming endotracheal tube placement. ILCOR has therefore prioritised a research question that needs to be urgently evaluated: 'In newborn infants receiving intermittent positive pressure ventilation by any non-invasive interface at birth, does the use of an ECO2 monitor in addition to clinical assessment, pulse oximetry and/or ECG, compared with clinical assessment, pulse oximetry and/or ECG only, decrease endotracheal intubation in the delivery room, improve response to resuscitation, improve survival or reduce morbidity?'. DESIGN Systematic review of randomised and non-randomised studies identified by Ovid MEDLINE, Embase and Cochrane CENTRAL search until 1 August 2022. SETTING Delivery room. PATIENTS Newborn infants receiving non-invasive ventilation at birth. INTERVENTION ECO2 measurement plus routine assessment compared with routine assessment alone. MAIN OUTCOME MEASURES Endotracheal intubation in the delivery room, response to resuscitation, survival and morbidity. RESULTS Among 2370 articles, 23 were included; however, none had a relevant control group. Although studies indicated that the absence of ECO2 may signify airway obstruction and ECO2 detection may precede a heart rate increase in adequately ventilated infants, they did not directly address the research question. CONCLUSIONS Evidence to support the use of an ECO2 monitor to guide non-invasive positive pressure ventilation at birth is lacking. More research on the effectiveness of ECO2 measurement in addition to routine assessment during non-invasive ventilation of newborn infants at birth is needed. PROSPERO REGISTRATION NUMBER CRD42022344849.
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Affiliation(s)
- Vix Monnelly
- Department of Neonatology, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Justin B Josephsen
- Department of Pediatrics, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Tetsuya Isayama
- Division of Neonatology, Center of Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation and Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Myra H Wyckoff
- Pediatrics, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Gary Weiner
- Department of Pediatrics, Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Helen G Liley
- Mater Research Institute, The University of Queensland, South Brisbane, QLD, Australia
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Gunawardana S, Arattu Thodika FMS, Murthy V, Bhat P, Williams EE, Dassios T, Milner AD, Greenough A. Respiratory function monitoring during early resuscitation and prediction of outcomes in prematurely born infants. J Perinat Med 2023; 51:950-955. [PMID: 36800988 DOI: 10.1515/jpm-2022-0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/25/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVES Over the last decade, there has been increased use of end-tidal carbon dioxide (ETCO2) and oxygen saturation (SpO2) monitoring during resuscitation of prematurely born infants in the delivery suite. Our objectives were to test the hypotheses that low end-tidal carbon dioxide (ETCO2) levels, low oxygen saturations (SpO2) and high expiratory tidal volumes (VTE) during the early stages of resuscitation would be associated with adverse outcomes in preterm infants. METHODS Respiratory recordings made in the first 10 min of resuscitation in the delivery suite of 60 infants, median GA 27 (interquartile range 25-29) weeks were analysed. The results were compared of infants who did or did not die or did or did not develop intracerebral haemorrhage (ICH) or bronchopulmonary dysplasia (BPD). RESULTS Twenty-five infants (42%) developed an ICH and 23 (47%) BPD; 11 (18%) died. ETCO2 at approximately 5 min after birth was lower in infants who developed an ICH, this remained significant after adjusting for gestational age, coagulopathy and chorioamnionitis (p=0.03). ETCO2 levels were lower in infants who developed ICH or died compared to those that survived without ICH, which remained significant after adjustment for gestational age, Apgar score at 10 min, chorioamnionitis and coagulopathy (p=0.004). SpO2 at approximately 5 min was lower in the infants who died compared to those who survived which remained significant after adjusting for the 5-min Apgar score and chorioamnionitis (p=0.021). CONCLUSIONS ETCO2 and SpO2 levels during early resuscitation in the delivery suite were associated with adverse outcomes.
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Affiliation(s)
- Shannon Gunawardana
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fahad M S Arattu Thodika
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- Neonatal Intensive Care Centre, Barts Health NHS Trust, London, UK
| | - Prashanth Bhat
- Neonatal Intensive Care Centre, Brighton and Sussex University Hospital, Sussex, UK
| | - Emma E Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony D Milner
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Shah D, Tracy M, Hinder M, Badawi N. Quantitative end-tidal carbon dioxide at initiation of resuscitation may help guide the ventilation of infants born at less than 30 weeks gestation. Acta Paediatr 2023; 112:652-658. [PMID: 36541873 DOI: 10.1111/apa.16639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/18/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
AIM Estimation of end-tidal carbon dioxide (EtCO2 ) with capnography can guide mask ventilation in infants born at less than 30 weeks of gestation. Chemical-sensitive colorimetric devices to detect CO2 are widely used at resuscitation. We aimed to quantify EtCO2 in the first breaths following initiation of mask ventilation at birth and correlated need for endotracheal intubation. METHODS Infants <30 weeks gestation receiving mask ventilation were randomised into two groups of mask-hold technique (one-person vs. two-person). Data on EtCO2 in the first 30 breaths, time to achieve 5 mmHg, 10 mmHg and 15 mmHg CO2 using a respiratory function monitor was determined. RESULTS Twenty-five infants with a mean gestation of 27.3 (±3 weeks) and mean birth weight 920.4 (±188.3 g) were analysed. The median EtCO2 was 5.6 mmHg in the first 10 breaths, whereas it was 12.6 mmHg for 11-20 breaths and 18 mmHg for 21-30 breaths. There was no significant difference in maximum median EtCO2 for the first 20 breaths, although EtCO2 was significantly lower in infants who were intubated (32.0 vs. 15.0, p = 0.018). CONCLUSION EtCO2 monitoring in infants <30 weeks gestation at birth is feasible and reflective of alveolar ventilation. EtCO2 may help guide ventilation of preterm infants at birth.
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Affiliation(s)
- Dharmesh Shah
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Mark Tracy
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Murray Hinder
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Nadia Badawi
- University of Sydney, Sydney, New South Wales, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Cerebral Palsy Research Institute, Cerebral Palsy Alliance, University of Sydney, Sydney, New South Wales, Australia
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Greenough A, Milner AD. Early origins of respiratory disease. J Perinat Med 2023; 51:11-19. [PMID: 35786507 DOI: 10.1515/jpm-2022-0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 01/20/2023]
Abstract
Chronic respiratory morbidity is unfortunately common in childhood, particularly in those born very prematurely or with congenital anomalies affecting pulmonary development and those with sickle cell disease. Our research group, therefore, has focused on the early origins of chronic respiratory disease. This has included assessing antenatal diagnostic techniques and potentially therapeutic interventions in infants with congenital diaphragmatic hernia. Undertaking physiological studies, we have increased the understanding of the premature baby's response to resuscitation and evaluated interventions in the delivery suite. Mechanical ventilation modes have been optimised and randomised controlled trials (RCTs) with short- and long-term outcomes undertaken. Our studies highlighted respiratory syncytial virus lower respiratory tract infections (LRTIs) and other respiratory viral LRTIs had an adverse impact on respiratory outcomes of prematurely born infants, who we demonstrated have a functional and genetic predisposition to respiratory viral LRTIs. We have described the long-term respiratory outcomes for children with sickle cell disease and importantly identified influencing factors. In conclusion, it is essential to undertake long term follow up of infants at high risk of chronic respiratory morbidity if effective preventative strategies are to be developed.
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Affiliation(s)
- Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anthony David Milner
- NIHR Biomedical Research Centre Based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Abstract
Mechanical ventilation can be life-saving for the premature infant, but is often injurious to immature and underdeveloped lungs. Lung injury is caused by atelectrauma, oxygen toxicity, and volutrauma. Lung protection must include appropriate lung recruitment starting in the delivery suite and throughout mechanical ventilation. Strategies include open lung ventilation, positive end-expiratory pressure, and volume-targeted ventilation. Respiratory function monitoring, such as capnography and ventilator graphics, provides clinicians with continuous real-time information and an adjunct to optimize lung-protective ventilatory strategies. Further research is needed to assess which lung-protective strategies result in a decrease in long-term respiratory morbidity.
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Bruckner M, Schmölzer GM. Physiologic Changes during Neonatal Transition and the Influence of Respiratory Support. Clin Perinatol 2021; 48:697-709. [PMID: 34774204 DOI: 10.1016/j.clp.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria.
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Holte K, Ersdal H, Klingenberg C, Eilevstjønn J, Stigum H, Jatosh S, Kidanto H, Størdal K. Expired carbon dioxide during newborn resuscitation as predictor of outcome. Resuscitation 2021; 166:121-128. [PMID: 34098031 DOI: 10.1016/j.resuscitation.2021.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/26/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022]
Abstract
AIM To explore and compare expired CO2 (ECO2) and heart rate (HR), during newborn resuscitation with bag-mask ventilation, as predictors of 24-h outcome. METHODS Observational study from March 2013 to June 2017 in a rural Tanzanian hospital. Side-stream measures of ECO2, ventilation parameters, HR, clinical information, and 24-h outcome were recorded in live born bag-mask ventilated newborns with initial HR < 120 bpm. We analysed the data using logistic regression models and compared areas under the receiver operating curves (AUC) for ECO2 and HR within three selected time intervals after onset of ventilation (0-30 s, 30.1-60 s and 60.1-300 s). RESULTS Among 434 included newborns (median birth weight 3100 g), 378 were alive at 24 h, 56 had died. Both ECO2 and HR were independently significant predictors of 24-h outcome, with no differences in AUCs. In the first 60 s of ventilation, ECO2 added extra predictive information compared to HR alone. After 60 s, ECO2 lost significance when adjusted for HR. In 70% of newborns with initial ECO2 <2% and HR < 100 bpm, ECO2 reached ≥2% before HR ≥ 100 bpm. Survival at 24 h was reduced by 17% per minute before ECO2 reached ≥2% and 44% per minute before HR reached ≥100 bpm. CONCLUSIONS Higher levels and a faster rise in ECO2 and HR during newborn resuscitation were independently associated with improved survival compared to persisting low values. ECO2 increased before HR and may serve as an earlier predictor of survival.
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Affiliation(s)
- Kari Holte
- Department of Paediatrics and Adolescence Medicine, Østfold Hospital Trust, Norway; Faculty of Health Sciences, University of Stavanger, Norway.
| | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, Norway; Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Norway
| | - Claus Klingenberg
- Department of Paediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway; Paediatric Research Group, Faculty of Health Sciences, University of Tromsø - Arctic University of Norway, Tromsø, Norway
| | - Joar Eilevstjønn
- Strategic Research Department, Laerdal Medical, Stavanger, Norway
| | - Hein Stigum
- Norwegian Institute of Public Health, Oslo, Norway
| | | | - Hussein Kidanto
- Medical College, Agakhan University, Dar es Salaam, Tanzania
| | - Ketil Størdal
- Department of Paediatrics and Adolescence Medicine, Østfold Hospital Trust, Norway; Norwegian Institute of Public Health, Oslo, Norway; Department of Paediatric Research, Faculty of Medicine, University of Oslo, Norway
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Weydig H, Ali N, Kakkilaya V. Noninvasive Ventilation in the Delivery Room for the Preterm Infant. Neoreviews 2020; 20:e489-e499. [PMID: 31477597 DOI: 10.1542/neo.20-9-e489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A decade ago, preterm infants were prophylactically intubated and mechanically ventilated starting in the delivery room; however, now the shift is toward maintaining even the smallest of neonates on noninvasive respiratory support. The resuscitation of very low gestational age neonates continues to push the boundaries of neonatal care, as the events that transpire during the golden minutes right after birth prove ever more important for determining long-term neurodevelopmental outcomes. Continuous positive airway pressure (CPAP) remains the most important mode of noninvasive respiratory support for the preterm infant to establish and maintain functional residual capacity and decrease ventilation/perfusion mismatch. However, the majority of extremely low gestational age infants require face mask positive pressure ventilation during initial stabilization before receiving CPAP. Effectiveness of face mask positive pressure ventilation depends on the ability to detect and overcome mask leak and airway obstruction. In this review, the current evidence on devices and techniques of noninvasive ventilation in the delivery room are discussed.
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Affiliation(s)
- Heather Weydig
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Noorjahan Ali
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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King A, Blank D, Bhatia R, Marzbanrad F, Malhotra A. Tools to assess lung aeration in neonates with respiratory distress syndrome. Acta Paediatr 2020; 109:667-678. [PMID: 31536658 DOI: 10.1111/apa.15028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/26/2019] [Accepted: 09/17/2019] [Indexed: 12/31/2022]
Abstract
AIM Respiratory distress syndrome is a common condition among preterm neonates, and assessing lung aeration assists in diagnosing the disease and helping to guide and monitor treatment. We aimed to identify and analyse the tools available to assess lung aeration in neonates with respiratory distress syndrome. METHODS A systematic review and narrative synthesis of studies published between January 1, 2004, and August 26, 2019, were performed using the OVID Medline, PubMed, Embase and Scopus databases. RESULTS A total of 53 relevant papers were retrieved for the narrative synthesis. The main tools used to assess lung aeration were respiratory function monitoring, capnography, chest X-rays, lung ultrasound, electrical impedance tomography and respiratory inductive plethysmography. This paper discusses the evidence to support the use of these tools, including their advantages and disadvantages, and explores the future of lung aeration assessments within neonatal intensive care units. CONCLUSION There are currently several promising tools available to assess lung aeration in neonates with respiratory distress syndrome, but they all have their limitations. These tools need to be refined to facilitate convenient and accurate assessments of lung aeration in neonates with respiratory distress syndrome.
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Affiliation(s)
- Arrabella King
- Department of Paediatrics Monash University Melbourne Vic. Australia
| | - Douglas Blank
- Monash Newborn Monash Children's Hospital Melbourne Vic. Australia
- The Ritchie Centre Hudson Institute of Medical Research Melbourne Vic. Australia
| | - Risha Bhatia
- Department of Paediatrics Monash University Melbourne Vic. Australia
- Monash Newborn Monash Children's Hospital Melbourne Vic. Australia
| | - Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering Monash University Melbourne Vic. Australia
| | - Atul Malhotra
- Department of Paediatrics Monash University Melbourne Vic. Australia
- Monash Newborn Monash Children's Hospital Melbourne Vic. Australia
- The Ritchie Centre Hudson Institute of Medical Research Melbourne Vic. Australia
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Abstract
Immediately after birth through spontaneous breaths, infants' clear lung liquid replacing it with air, and gradually establishing a functional residual capacity to achieve gas exchange. Most infants start breathing independently after birth and ~3% of infants who require positive pressure ventilation. When newborns fail to start breathing the current neonatal resuscitation guidelines recommend initiatingpositive pressure ventilationusing a face mask and a ventilation device. Adequate ventilation is the cornerstone of successful neonatal resuscitation; therefore, it is mandatory that anybody involved in neonatal resuscitation is trained in mask ventilation techniques. One of the main problems with mask ventilation is that it is very subjective with direct feedback lacking and not uncommonly, the resuscitator does not realise that their technique is unsatisfactory. Many studies have shown that monitoring tidal volume and leak around the mask or endotracheal tube enables the resuscitator to identify the problem and adjust their technique to reduce the leak and deliver and appropriate tidal volume. This chapter discusses the currently available monitoring devices used during stabilization/resuscitation in the delivery room.
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Affiliation(s)
- Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Colin J Morley
- Department of Obstetrics and Gynaecology, University of Cambridge, United Kingdom
| | - Omar C O F Kamlin
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
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Hunt KA, Murthy V, Bhat P, Fox GF, Campbell ME, Milner AD, Greenough A. Tidal volume monitoring during initial resuscitation of extremely prematurely born infants. J Perinat Med 2019; 47:665-670. [PMID: 31103996 DOI: 10.1515/jpm-2018-0389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/14/2019] [Indexed: 11/15/2022]
Abstract
Background Airway obstruction can occur during facemask (FM) resuscitation of preterm infants at birth. Intubation bypasses any upper airway obstruction. Thus, it would be expected that the occurrence of low expiratory tidal volumes (VTes) would be less in infants resuscitated via an endotracheal tube (ETT) rather than via an FM. Our aim was to test this hypothesis. Methods Analysis was undertaken of respiratory function monitoring traces made during initial resuscitation in the delivery suite to determine the peak inflating pressure (PIP), positive end expiratory pressure (PEEP), the VTe and maximum exhaled carbon dioxide (ETCO2) levels and the number of inflations with a low VTe (less than 2.2 mL/kg). Results Eighteen infants were resuscitated via an ETT and 11 via an FM, all born at less than 29 weeks of gestation. Similar inflation pressures were used in both groups (17.2 vs. 18.8 cmH2O, P = 0.67). The proportion of infants with a low median VTe (P = 0.6) and the proportion of inflations with a low VTe were similar in the groups (P = 0.10), as was the lung compliance (P = 0.67). Infants with the lowest VTe had the stiffest lungs (P < 0.001). Conclusion Respiratory function monitoring during initial resuscitation can objectively identify infants who may require escalation of inflation pressures.
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Affiliation(s)
- Katie A Hunt
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Prashanth Bhat
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Grenville F Fox
- Neonatal Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Anthony D Milner
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust and King's College London, London, UK.,NICU, 4Floor Golden Jubilee Wing, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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Cereceda-Sánchez FJ, Molina-Mula J. Systematic Review of Capnography with Mask Ventilation during Cardiopulmonary Resuscitation Maneuvers. J Clin Med 2019; 8:E358. [PMID: 30871214 PMCID: PMC6463178 DOI: 10.3390/jcm8030358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 02/05/2023] Open
Abstract
The latest guidelines identify capnography as an instrument used to assess bag-valve-mask ventilation during cardiopulmonary resuscitation (CPR). In this review, we analyzed the feasibility and reliability of capnography use with face mask ventilation during CPR maneuvers in adults and children. This systematic review was completed in December 2018; data for the study were obtained from the following databases: EBSCOhost, SCOPUS, PubMed, Índice Bibliográfico Español en Ciencias de la Salud (IBECS), TESEO, and Cochrane Library Plus. Two reviewers independently assessed the eligibility of the articles; we analyzed publications from different sources and identified studies that focused on the use of capnography with a face mask during CPR maneuvers in order to describe the capnometry value and its correlation with resuscitation outcomes and the assistance of professionals. A total of 888 papers were collected, and 17 papers were included that provided objective values for the use of capnography with a mask for ventilation. Four were randomized clinical trials (RCT) and the rest were observational studies. Four studies were completed in adults and 13 were completed in newborns. After the analysis of the papers, we recommended a capnographic level of C in adults and B in newborns. Despite the little evidence obtained, capnography has been demonstrated to facilitate the advanced clinical practice of mask ventilation in cardiopulmonary resuscitation, to be reliable in the early detection of heart rate increase in newborns, and to asses in-airway patency and lung aeration during newborn resuscitation.
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Affiliation(s)
| | - Jesús Molina-Mula
- Physiotherapy Department at the University of Balearic Islands, Ctra. de Valldemossa, km 7.5, 07122 Palma de Mallorca, Balearic Islands, Spain.
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Cereceda-Sánchez F, Molina-Mula J. Systematic Review of Capnography with Mask Ventilation during Cardiopulmonary Resuscitation Maneuvers. J Clin Med 2019. [DOI: https://doi.org/10.3390/jcm8030358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The latest guidelines identify capnography as an instrument used to assess bag-valve-mask ventilation during cardiopulmonary resuscitation (CPR). In this review, we analyzed the feasibility and reliability of capnography use with face mask ventilation during CPR maneuvers in adults and children. This systematic review was completed in December 2018; data for the study were obtained from the following databases: EBSCOhost, SCOPUS, PubMed, Índice Bibliográfico Español en Ciencias de la Salud (IBECS), TESEO, and Cochrane Library Plus. Two reviewers independently assessed the eligibility of the articles; we analyzed publications from different sources and identified studies that focused on the use of capnography with a face mask during CPR maneuvers in order to describe the capnometry value and its correlation with resuscitation outcomes and the assistance of professionals. A total of 888 papers were collected, and 17 papers were included that provided objective values for the use of capnography with a mask for ventilation. Four were randomized clinical trials (RCT) and the rest were observational studies. Four studies were completed in adults and 13 were completed in newborns. After the analysis of the papers, we recommended a capnographic level of C in adults and B in newborns. Despite the little evidence obtained, capnography has been demonstrated to facilitate the advanced clinical practice of mask ventilation in cardiopulmonary resuscitation, to be reliable in the early detection of heart rate increase in newborns, and to asses in-airway patency and lung aeration during newborn resuscitation.
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Hunt KA, Yamada Y, Murthy V, Srihari Bhat P, Campbell M, Fox GF, Milner AD, Greenough A. Detection of exhaled carbon dioxide following intubation during resuscitation at delivery. Arch Dis Child Fetal Neonatal Ed 2019; 104:F187-F191. [PMID: 29550769 DOI: 10.1136/archdischild-2017-313982] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES End tidal carbon dioxide (ETCO2) monitoring can facilitate identification of successful intubation. The aims of this study were to determine the time to detect ETCO2 following intubation during resuscitation of infants born prematurely and whether it differed according to maturity at birth or the Apgar scores (as a measure of the infant's condition after birth). DESIGN Analysis of recordings of respiratory function monitoring. SETTING Two tertiary perinatal centres. PATIENTS Sixty-four infants, with median gestational age of 27 (range 23-34)weeks. INTERVENTIONS Respiratory function monitoring during resuscitation in the delivery suite. MAIN OUTCOME MEASURES The time following intubation for ETCO2 levels to be initially detected and to reach 4 mm Hg and 15 mm Hg. RESULTS The median time for initial detection of ETCO2 following intubation was 3.7 (range 0-44) s, which was significantly shorter than the median time for ETCO2 to reach 4 mm Hg (5.3 (range 0-727) s) and to reach 15 mm Hg (8.1 (range 0-827) s) (both P<0.001). There were significant correlations between the time for ETCO2 to reach 4 mm Hg (r=-0.44, P>0.001) and 15 mm Hg (r=-0.48, P<0.001) and gestational age but not with the Apgar scores. CONCLUSIONS The time for ETCO2 to be detected following intubation in the delivery suite is variable emphasising the importance of using clinical indicators to assess correct endotracheal tube position in addition to ETCO2 monitoring. Capnography is likely to detect ETCO2 faster than colorimetric devices.
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Affiliation(s)
- Katie A Hunt
- MRC & Asthma UK Centre in Allergic Mechanisms in Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Yosuke Yamada
- MRC & Asthma UK Centre in Allergic Mechanisms in Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- MRC & Asthma UK Centre in Allergic Mechanisms in Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Prashanth Srihari Bhat
- MRC & Asthma UK Centre in Allergic Mechanisms in Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Morag Campbell
- Neonatal Unit, Southern General and Yorkhill Hospitals, Scotland, UK
| | - Grenville F Fox
- Evelina Children's Hospital Neonatal Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Anthony D Milner
- MRC & Asthma UK Centre in Allergic Mechanisms in Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- MRC & Asthma UK Centre in Allergic Mechanisms in Asthma, King's College London, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
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15
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Pahuja A, Hunt K, Murthy V, Bhat P, Bhat R, Milner AD, Greenough A. Relationship of resuscitation, respiratory function monitoring data and outcomes in preterm infants. Eur J Pediatr 2018; 177:1617-1624. [PMID: 30066181 DOI: 10.1007/s00431-018-3222-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/26/2022]
Abstract
Intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD) are major complications of premature birth. We tested the hypotheses that prematurely born infants who developed an IVH or BPD would have high expiratory tidal volumes (VTE) (VTE > 6 ml/kg) and/or low-end tidal carbon dioxide (ETCO2) levels (ETCO2 levels < 4.5 kPa) as recorded by respiratory function monitoring or hyperoxia (oxygen saturation (SaO2) > 95%) during resuscitation in the delivery suite. Seventy infants, median gestational age 27 weeks (range 23-33), were assessed; 31 developed an IVH and 43 developed BPD. Analysis was undertaken of 31,548 inflations. The duration of resuscitation did not differ significantly between the groups. Those who developed an IVH compared to those who did not had a greater number of inflations with a high VTE and a low ETCO2, which remained significant after correcting for differences in gestational age and birth weight between groups (p = 0.019). Differences between infants who did and did not develop BPD were not significant after correcting for differences in gestational age and birth weight. There were no significant differences in the duration of hyperoxia between the groups.Conclusions: Avoidance of high tidal volumes and hypocarbia in the delivery suite might reduce IVH development. What is known • Hypocarbia on the neonatal unit is associated with the development of intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD). What is new • Infants who developed an IVH compared to those who did not had significantly more inflations with high expiratory tidal volumes and low ETCO2s.
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Affiliation(s)
- Anoop Pahuja
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Katie Hunt
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Prashanth Bhat
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony D Milner
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust, King's College London, London, UK.
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16
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Foglia EE, te Pas AB. Effective ventilation: The most critical intervention for successful delivery room resuscitation. Semin Fetal Neonatal Med 2018; 23:340-346. [PMID: 29705089 PMCID: PMC6288818 DOI: 10.1016/j.siny.2018.04.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Lung aeration is the critical first step that triggers the transition from fetal to postnatal cardiopulmonary physiology after birth. When an infant is apneic or does not breathe sufficiently, intervention is needed to support this transition. Effective ventilation is therefore the cornerstone of neonatal resuscitation. In this article, we review the physiology of cardiopulmonary transition at birth, with particular attention to factors the caregiver should consider when providing ventilation. We then summarize the available clinical evidence for strategies to monitor and perform positive pressure ventilation in the delivery room setting.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA,
| | - Arjan B. te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands,
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17
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Ngan AY, Cheung PY, Hudson-Mason A, O'Reilly M, van Os S, Kumar M, Aziz K, Schmölzer GM. Using exhaled CO 2 to guide initial respiratory support at birth: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2017; 102:F525-F531. [PMID: 28596379 DOI: 10.1136/archdischild-2016-312286] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/21/2017] [Accepted: 03/26/2017] [Indexed: 11/04/2022]
Abstract
IMPORTANCE A sustained inflation (SI) provided at birth might reduce bronchopulmonary dysplasia (BPD). OBJECTIVE This study aims to examine whether an SI-guided exhaled carbon dioxide (ECO2) compared with positive pressure ventilation (PPV) alone at birth decreases BPD. DESIGN Randomised controlled trial. Infants were randomly allocated to either SI (SI group) or PPV (PPV group). PARTICIPANTS Participants of this study include infants between 23+0 and 32+6 weeks gestation with a need for PPV at birth. INTERVENTION Infants randomised into the SI group received an initial SI with a peak inflation pressure (PIP) of 24 cmH2O over 20 s. The second SI was guided by the amount of ECO2. If ECO2 was ≤20 mm Hg, a further SI of 20 s was delivered. If ECO2 was >20 mm Hg the second SI was 10 s. Infants randomised into the PPV group received mask PPV with an initial PIP of 24 cmH2O. PRIMARY OUTCOMES Reduction in BPD defined as the need for respiratory support or supplemental oxygen at corrected gestational age of 36 weeks. RESULTS SI (n=76) and PPV (n=86) group had similar rates of BPD (23% vs 33%, p=0.090, not statistically significant). The duration of mechanical ventilation was significantly reduced with SI versus PPV (63 (10-246) hours versus 204 (17-562) hours, respectively (p=0.045)). No short-term harmful effects were identified from two SI lasting up to 40 s (eg, pneumothorax, intraventricular haemorrhage or patent ductus arteriosus). CONCLUSION Preterm infants <33 weeks gestation receiving SI at birth had lower duration of mechanical ventilation and similar incidence of BPD compared with PPV. Using ECO2 to guide length of SI is feasible. TRIAL REGISTRATION NUMBER NCT01739114; Results.
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Affiliation(s)
- Ashley Y Ngan
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Ann Hudson-Mason
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Sylvia van Os
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Manoj Kumar
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Khalid Aziz
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Georg M Schmölzer
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
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18
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Bhat P, Hunt K, Harris C, Murthy V, Milner AD, Greenough A. Inflation pressures and times during initial resuscitation in preterm infants. Pediatr Int 2017; 59:906-910. [PMID: 28477341 DOI: 10.1111/ped.13319] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/20/2017] [Accepted: 04/28/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND The optimal combination of inflation pressures and times to produce adequate expiratory tidal volumes during initial resuscitation in prematurely born infants has not been determined. The aim of this study was therefore to assess combinations of inflation pressures and times and the resulting expiratory tidal volume levels using a respiratory function monitor. METHODS Sixty-four infants born before 34 weeks of gestation were studied. The infants were divided according to whether the inflation pressure (peak inflation pressure minus positive end expiratory pressure) was < or ≥20 cmH2 O during the first five inflations delivered by a face mask, and those groups were then subdivided according to whether the inflation time was < or ≥1.5 s. RESULTS Inflation pressure ≥20 cmH2 O compared with lower pressure at both inflation times produced significantly higher expiratory tidal volume. Longer compared with shorter inflation times when the inflation pressure was ≥20 cmH2 O resulted in no significant difference in expiratory tidal volume. At <20 cmH2 O inflation pressure, longer inflation time overall resulted in higher end tidal volume, but the majority of infants had a tidal volume less than the anatomical dead space. CONCLUSIONS At higher inflation pressure, a longer inflation time was not necessary to increase expiratory tidal volume.
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Affiliation(s)
- Prashanth Bhat
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Katie Hunt
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Christopher Harris
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Vadivelam Murthy
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Anthony D Milner
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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19
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Hawkes GA, Finn D, Kenosi M, Livingstone V, O'Toole JM, Boylan GB, O'Halloran KD, Ryan AC, Dempsey EM. A Randomized Controlled Trial of End-Tidal Carbon Dioxide Detection of Preterm Infants in the Delivery Room. J Pediatr 2017; 182:74-78.e2. [PMID: 27939108 DOI: 10.1016/j.jpeds.2016.11.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/15/2016] [Accepted: 11/01/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the ability of qualitative versus quantitative methods of end-tidal carbon dioxide (EtCO2) detection to maintain normocarbia during face mask ventilation (FMV) of preterm infants (<32 weeks) in the delivery room. STUDY DESIGN Preterm infants <32 weeks were randomly assigned to the use of a disposable PediCap EtCO2 detector (Covidien, Dublin, Ireland) (qualitative) or a Microstream side stream capnography device (Covidien) (quantitative) for FMV in the delivery room, via a NeoPuff T-piece resuscitator (Fisher and Paykel, Auckland, New Zealand). The primary outcome was the presence of normocarbia, based on partial pressure of CO2 (PaCO2) readings obtained in the neonatal intensive care unit within an hour of birth. Normocarbia was defined as a PaCO2 measure between 37.5 and 60 mm Hg (5-8 kPa). RESULTS Of the 59 infants included, 59% (35/59) were within the PaCO2 target range within an hour of birth. There was no difference in the primary outcome; 64% (21/33) of infants in the quantitative group were within the PaCO2 range compared with 54% (14/26) in the qualitative group (P = .594); and 93% of participants <28 weeks' gestation were within the PaCO2 normocarbic range (90% [9/10] in quantitative group and 100% [5/5] in the qualitative group [P = 1]). There was no difference in the intubation rate, days of ventilation, or bronchopulmonary dysplasia rates between the 2 groups. CONCLUSIONS Quantitative or qualitative EtCO2 detection methods are both feasible for FMV in the delivery room. Although there was no difference in the incidence of normocarbia, the use of either form of EtCO2 monitoring should be considered during newborn stabilization, especially in infants less than 28 weeks' gestation. TRIAL REGISTRATION ISRCTN: ISRCTN10934870.
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Affiliation(s)
- Gavin A Hawkes
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Daragh Finn
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Mmoloki Kenosi
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Vicki Livingstone
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - John M O'Toole
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, University College Cork, Cork, Ireland
| | - Anthony C Ryan
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Pediatrics and Child Health, Neonatal Intensive Care Unit, Wilton, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
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20
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Harris C, Bhat P, Murthy V, Milner AD, Greenough A. The first breath during resuscitation of prematurely born infants. Early Hum Dev 2016; 100:7-10. [PMID: 27379613 DOI: 10.1016/j.earlhumdev.2016.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/09/2016] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The first five initial inflation pressures and times during resuscitation of prematurely born infants are frequently lower than those recommended and rarely result in tidal volumes exceeding the anatomical dead space. Greater volumes were produced when the infant was provoked to inspire by an inflation (active inflation). AIMS To assess factors associated with a shorter time to the first active inflation. STUDY DESIGN Respiratory function monitoring was undertaken during resuscitation, peak inflation pressures (PIP), inflation times and the infant's respiratory activity were simultaneously recorded. SUBJECTS Infants with a gestational age<34weeks requiring resuscitation at birth. OUTCOME MEASURES The relationships of the PIP and inflation time of the first five inflations and first active inflation to the time to the first active inflation. RESULTS Recordings from 47 infants, median gestational age of 29 (23-34) weeks, were analysed. The median PIP of the first five inflations was 27 (range 9-37) cmH2O and inflation time 1.22 (range 0.32-4.08) s. The median PIP of the first active inflation was 25 (range 19-37) cmH2O and inflation time 1.35 (0.35-3.67) s. The median time to the first active inflation was 7 (range 0-50) seconds and was inversely correlated with the PIP (p=0.001) and inflation time (p=0.018) of the first five inflations and the PIP (p=0.001) and inflation time (p=0.008) of the first active inflation. CONCLUSION The magnitude of the inflation pressures and times of the first five inflations inversely correlate with the time to the first breath during resuscitation.
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Affiliation(s)
- Christopher Harris
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK.
| | - Prashant Bhat
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK.
| | - Vadivelam Murthy
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK.
| | - Anthony D Milner
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK.
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK; NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust and King's College London, UK.
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21
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Boldingh AM, Solevåg AL, Benth JŠ, Klingenberg C, Nakstad B. Newborn manikin study shows that physicians often fail to detect correct lung compliance when using a self-inflating bag. Acta Paediatr 2016; 105:172-7. [PMID: 26153507 DOI: 10.1111/apa.13114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/11/2015] [Accepted: 07/01/2015] [Indexed: 11/30/2022]
Abstract
AIM Recognising changes in lung compliance can help clinicians to adjust initial inflations during resuscitation at birth. We examined whether physicians sensed low and normal compliance with a self-inflating bag before and after an educational intervention that used a manikin connected to a newborn lung simulator. METHODS We asked 43 physicians with neonatal duties to perform two low compliance ventilation attempts and two normal-compliance ventilation attempts in a randomised order at baseline and after the educational intervention, with 34 taking part in a retest three months later. RESULTS The physicians correctly recognised low and normal compliance in 71% and 66% of the ventilations at baseline, 80% and 66% of the ventilations after the intervention and 74% and 81% at retest. Correct recognition of normal compliance improved from baseline to retest (p = 0.04). Ventilations in low- vs normal-compliance settings resulted in lower tidal volumes (4.4 vs 23.0 mL, p < 0.001), lower ventilation rates (42 vs 51, p < 0.001) and higher peak inflating pressure (35.2 vs 31.4 cmH2 O, p < 0.001). CONCLUSION Around one in four physicians failed to recognise correct compliance levels when using a self-inflating bag and showed limited improvement after an educational intervention. Ventilations in a low-compliance setting resulted in suboptimal ventilation.
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Affiliation(s)
- Anne Marthe Boldingh
- Department of Paediatric and Adolescent Medicine; Akershus University Hospital; Akershus Norway
- Institute of Clinical Medicine; Campus Akershus University Hospital; University of Oslo; Oslo Norway
| | - Anne Lee Solevåg
- Department of Paediatric and Adolescent Medicine; Akershus University Hospital; Akershus Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine; Campus Akershus University Hospital; University of Oslo; Oslo Norway
- HØKH; Research Centre; Akershus University Hospital; Lørenskog Norway
| | - Claus Klingenberg
- Department of Paediatrics; University Hospital of North Norway; Tromsø Norway
- Paediatric Research Group; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
| | - Britt Nakstad
- Department of Paediatric and Adolescent Medicine; Akershus University Hospital; Akershus Norway
- Institute of Clinical Medicine; Campus Akershus University Hospital; University of Oslo; Oslo Norway
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22
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Finn D, Boylan GB, Ryan CA, Dempsey EM. Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room. Front Pediatr 2016; 4:30. [PMID: 27066463 PMCID: PMC4814766 DOI: 10.3389/fped.2016.00030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/18/2016] [Indexed: 11/13/2022] Open
Abstract
Monitoring of preterm infants in the delivery room (DR) remains limited. Current guidelines suggest that pulse oximetry should be available for all preterm infant deliveries, and that if intubated a colorimetric carbon dioxide detector should provide verification of correct endotracheal tube placement. These two methods of assessment represent the extent of objective monitoring of the newborn commonly performed in the DR. Monitoring non-invasive ventilation effectiveness (either by capnography or respiratory function monitoring) and cerebral oxygenation (near-infrared spectroscopy) is becoming more common within research settings. In this article, we will review the different modalities available for cardiorespiratory and neuromonitoring in the DR and assess the current evidence base on their feasibility, strengths, and limitations during preterm stabilization.
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Affiliation(s)
- Daragh Finn
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - C Anthony Ryan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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23
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Hawkes GA, Kenosi M, Finn D, O'Toole JM, O'Halloran KD, Boylan GB, Ryan AC, Dempsey EM. Delivery room end tidal CO2 monitoring in preterm infants <32 weeks. Arch Dis Child Fetal Neonatal Ed 2016; 101:F62-5. [PMID: 26304459 DOI: 10.1136/archdischild-2015-308315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 07/31/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the feasibility of end tidal (EtCO2) monitoring of preterm infants in the delivery room, to determine EtCO2 levels during delivery room stabilisation, and to examine the incidence of normocapnia (5-8 kPa) on admission to the neonatal intensive care unit in the EtCO2 monitored group compared with a historical cohort without EtCO2 monitoring. PATIENTS AND METHODS Preterm infants (<32 weeks) were eligible for inclusion in this observational study. The evolution of EtCO2 values immediately after delivery was assessed and linear least-squares methods were used to fit a line to EtCO2 recordings. The partial pressure of CO2 in blood (PCO2) from the infants who received EtCO2 monitoring was compared with a historical cohort without EtCO2 monitoring. RESULTS EtCO2 monitoring was feasible in the delivery room. EtCO2 values were successfully obtained in 39 (88.7%) of the 44 infants included in the study. EtCO2 gradually increased over the first 4 min. Intubated infants had higher EtCO2 values compared with infants who were not intubated, with median (IQR) values of 4.7 (3.3-8.4) kPa versus 3.2 (2.6-4.2) kPa (p=0.05). No difference was found between the proportions of PCO2 values within the range of normocapnia among infants who received EtCO2 monitoring compared with those who did not (56.8% vs 47.9%, p=0.396). CONCLUSIONS Delivery room EtCO2 monitoring is feasible and safe. EtCO2 values obtained after birth reflect the establishment of functional residual capacity and effective ventilation. The potential short-term and long-term consequences of EtCO2 monitoring should be established in randomised controlled trials.
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Affiliation(s)
- Gavin A Hawkes
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Mmoloki Kenosi
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Daragh Finn
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - John M O'Toole
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Anthony C Ryan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
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Nicoll J, Cheung PY, Aziz K, Rajani V, O'Reilly M, Pichler G, Schmölzer GM. Exhaled Carbon Dioxide and Neonatal Breathing Patterns in Preterm Infants after Birth. J Pediatr 2015; 167:829-833.e1. [PMID: 26227435 DOI: 10.1016/j.jpeds.2015.06.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/10/2015] [Accepted: 06/26/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the amount of exhaled carbon dioxide (ECO2) with different breathing patterns in spontaneously breathing preterm infants after birth. STUDY DESIGN Preterm infants had a facemask attached to a combined carbon dioxide/flow sensor placed over their mouth and nose to record ECO2 and gas flow. A breath-by-breath analysis of the first 5 minutes of the recording was performed. RESULTS Thirty spontaneously breathing preterm infants, gestational age (mean ± SD) 30 ± 2 weeks and birth weight 1635 ± 499 g were studied. ECO2 from normal breaths and slow expirations was significantly larger than with other breathing patterns (P < .001). ECO2 per breath also increased with gestational age P < .001. The expiratory hold pattern was the most prevalent breathing pattern both during the first minute of recording and overall. Breathing pattern proportions also varied by gestational age. Finally, ECO2 from the fifth minute of recording was significantly greater than that produced during the first 4 minutes of recording (P ≤ .029). CONCLUSIONS ECO2 varies with different breathing patterns and increases with gestational age and over time. ECO2 may be an indicator of lung aeration and that postnatal ECO2 monitoring may be useful in preterm infants in the delivery room.
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Affiliation(s)
- Jessica Nicoll
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Khalid Aziz
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Vishaal Rajani
- Neuroscience and Mental Health Institute, Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gerhard Pichler
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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25
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Hawkes GA, Kenosi M, Ryan CA, Dempsey EM. Quantitative or qualitative carbon dioxide monitoring for manual ventilation: a mannequin study. Acta Paediatr 2015; 104:e148-51. [PMID: 25495353 DOI: 10.1111/apa.12868] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/15/2014] [Accepted: 11/12/2014] [Indexed: 11/27/2022]
Abstract
AIM To compare the effectiveness of an in-line EtCO2 detector (DET) and a quantitative EtCO2 detector (CAP), both attached to a t-piece resuscitator, during PPV via a face mask. METHODS Paediatric trainees were randomly assigned to determine the method of PPV they commenced with (No device (ND), DET or CAP). Participants used each method for 2 min. Participants were video-recorded to determine the amount of effective ventilations delivered with each method. RESULTS Twenty-three paediatric trainees provided a total of 6035 ventilations, and 91.2% were deemed effective. The percentages of median effective ventilations with the ND, the DET and the CAP were 91.0%, 93.0% and 94.0%, respectively. Fourteen (61%) of the trainees indicated a preference for the DET method, 8 (35%) for the CAP method, and 1 (4%) of the trainees indicated a preference for the ND method. Capnography was the most effective method per patient. CONCLUSION There was no adverse effect with the addition of EtCO2 detectors. Trainees favoured methods of EtCO2 monitoring during ventilation. The NeoStat device was the preferred device by the majority. The greatest efficacy was achieved with the capnography device. Capnography may enhance face mask ventilation.
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Affiliation(s)
- GA Hawkes
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
| | - M Kenosi
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
| | - CA Ryan
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
| | - EM Dempsey
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
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Schmölzer GM, Hooper SB, Wong C, Kamlin COF, Davis PG. Exhaled carbon dioxide in healthy term infants immediately after birth. J Pediatr 2015; 166:844-9.e1-3. [PMID: 25596099 DOI: 10.1016/j.jpeds.2014.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/13/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To measure exhaled carbon dioxide (ECO2) in term infants immediately after birth. STUDY DESIGN Infants >37 weeks gestation born at The Royal Women's Hospital, Melbourne, Australia were eligible. A combined flow sensor and mainstream carbon dioxide (CO2) analyzer was placed in series proximal to a facemask to measure ECO2 and tidal volumes in the first 120 seconds after birth. RESULTS Term infants (n = 20) with a mean (SD) birth weight of 2976 (697) g and gestational age of 38 (2) weeks were included. Infants took a median (range) 3 (1-8) breaths before ECO2 was detected. The median (range) of maximum ECO2 was 51 (40-73) mm Hg at 70 (21-106) seconds after birth. Within the first 10 breaths, CO2 increased from 0-27 (22-34) mm Hg. The median (IQR) tidal volume during the breaths without CO2 was 1.2 (0.8-3.1) mL/kg compared with 7.3 (3.2-10.9) mL/kg during the first 10 breaths where CO2 was exhaled. CONCLUSIONS The first breaths for an infant after birth did not contain ECO2. With aeration of the distal gas exchange regions, tidal volume and ECO2 significantly increased. ECO2 can be used to monitor lung aeration immediately after birth.
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Affiliation(s)
- Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; The Ritchie Center, Monash University, Melbourne, Australia; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Critical Care Stream, Murdoch Children Research Institute, Melbourne, Australia
| | | | - Connie Wong
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - C Omar F Kamlin
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Critical Care Stream, Murdoch Children Research Institute, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Australia
| | - Peter G Davis
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Critical Care Stream, Murdoch Children Research Institute, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Australia
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Murthy V, D'Costa W, Shah R, Fox GF, Campbell ME, Milner AD, Greenough A. Prematurely born infants' response to resuscitation via an endotracheal tube or a face mask. Early Hum Dev 2015; 91:235-8. [PMID: 25706318 DOI: 10.1016/j.earlhumdev.2015.02.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/04/2015] [Accepted: 02/10/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prematurely born infants may be resuscitated in the labour suite via a face mask or an endotracheal tube. AIMS To assess prematurely born infants' initial responses to resuscitation delivered via an endotracheal tube or a face mask, to determine if the first five inflations via an endotracheal tube produced expired tidal volumes greater than 4.4ml/kg (twice the anatomical dead space) and whether the outcome of initial resuscitation via an endotracheal tube or via a face mask differed according to the first active inflation (the infant's inspiratory effort coinciding with an inflation). STUDY DESIGN Prospective observational study. SUBJECTS Thirty-five infants (median gestational age 25, range 23-27weeks) requiring resuscitation via an endotracheal tube (n=20) or a face mask (n=15) were studied. OUTCOME MEASURES Inflation pressures, inflation times, expiratory tidal volumes, end tidal carbon dioxide (ETCO2) and leak were recorded. RESULTS Before the first active inflation, only 27% of infants receiving resuscitation via an endotracheal tube had expiratory volumes greater than 4.4ml/kg. During, both endotracheal and face mask initial resuscitations, during the first active inflation the expired tidal volumes (7.7ml/kg, 5.2ml/kg) and ETCO2 levels (4.8kPa, 3.2kPa) were significantly higher than during the inflations before the first active inflation (2.8ml/kg, 1.6ml/kg; 0.36kPa, 0.2kPa respectively) (all p<0.001). CONCLUSIONS Initial resuscitation via an endotracheal tube using currently recommended pressures, rarely produced adequate tidal volumes. Resuscitation via an endotracheal tube or a face mask was most effective when the infant's inspiratory effort coincided with an inflation.
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Affiliation(s)
- Vadivelam Murthy
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK
| | - Walton D'Costa
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK
| | - Raajul Shah
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK
| | - Grenville F Fox
- Evelina Children's Hospital Neonatal Unit, Guy's & St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Morag E Campbell
- Neonatal Unit, Southern General Hospital, Scotland, UK; Neonatal Unit, Yorkhill Hospital, Scotland, UK
| | - Anthony D Milner
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, UK; NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust and King's College London, UK.
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Evaluation of respiratory function monitoring at the resuscitation of prematurely born infants. Eur J Pediatr 2015; 174:205-8. [PMID: 25029987 DOI: 10.1007/s00431-014-2379-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/01/2014] [Accepted: 07/02/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Our aim was to determine whether neonatal trainees found respiratory function monitoring (RFM) helpful during the resuscitation of prematurely born infants, what decisions they made on the basis of RFM and whether those decisions were evidence based. Fifty one trainees completed an electronic questionnaire. Eighty-three percent found the tidal volume display useful, 59 % altered the inflation pressure based on the tidal volume: 52 % considered 5 ml/kg adequate; 33 % 4 ml/kg; 13 % 6 ml/kg; and 2 % 7 ml/kg, despite no evidence on which to decide was the optimum tidal volume. If there was no detectable expired carbon dioxide (CO2), 30 trainees said they would reintubate, yet the absence of expired CO2 can indicate inadequate vasodilation of the pulmonary circulation rather than inappropriate placement of the endotracheal tube. If there was no chest wall expansion, but expired CO2, a third of junior trainees would reintubate which is inappropriate. If the oxygen saturation (SaO2) was <85 % at 1 min, no senior trainee, but 50 % of junior trainees would increase the inspired oxygen. The majority of healthy babies have an SaO2 > 85 % by 1 min. CONCLUSIONS The usefulness of respiratory function monitoring for trainees during neonatal resuscitation is often not evidence based.
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van Os S, Cheung PY, Pichler G, Aziz K, O'Reilly M, Schmölzer GM. Exhaled carbon dioxide can be used to guide respiratory support in the delivery room. Acta Paediatr 2014; 103:796-806. [PMID: 24698203 DOI: 10.1111/apa.12650] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/04/2014] [Accepted: 04/01/2014] [Indexed: 11/30/2022]
Abstract
UNLABELLED Respiratory support in the delivery room remains challenging. Assessing chest rise is imprecise, and mask leak and airway obstruction are common problems. We describe recordings of respiratory signals during delivery room resuscitations and discuss guidance on positive-pressure ventilation using respiratory parameters and exhaled carbon dioxide (ECO2 ) during neonatal resuscitations. CONCLUSION Observing tidal volume and ECO2 waveforms adds objectivity to clinical assessments. ECO2 could help assess lung aeration and improve lung recruitment immediately after birth.
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Affiliation(s)
- Sylvia van Os
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
| | - Po-Yin Cheung
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Gerhard Pichler
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; Medical University Graz; Graz Austria
| | - Khalid Aziz
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Megan O'Reilly
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Georg M. Schmölzer
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; Medical University Graz; Graz Austria
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Hawkes GA, Kelleher J, Ryan CA, Dempsey EM. A review of carbon dioxide monitoring in preterm newborns in the delivery room. Resuscitation 2014; 85:1315-9. [PMID: 25086296 DOI: 10.1016/j.resuscitation.2014.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/14/2014] [Accepted: 07/18/2014] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements. AIM To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room. METHODS Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials. RESULTS The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B. DISCUSSION CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.
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Affiliation(s)
- G A Hawkes
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland
| | - J Kelleher
- Department of Neonatology, University Maternity Hospital Limerick, Ireland
| | - C A Ryan
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland
| | - E M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland.
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Kang LJ, Cheung PY, Pichler G, O’Reilly M, Aziz K, Schmölzer GM. Monitoring lung aeration during respiratory support in preterm infants at birth. PLoS One 2014; 9:e102729. [PMID: 25029553 PMCID: PMC4100902 DOI: 10.1371/journal.pone.0102729] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/22/2014] [Indexed: 11/22/2022] Open
Abstract
Background If infants fail to initiate spontaneous breathing, resuscitation guidelines recommend respiratory support with positive pressure ventilation (PPV). The purpose of PPV is to establish functional residual capacity and deliver an adequate tidal volume (VT) to achieve gas exchange. Objective The aim of our pilot study was to measure changes in exhaled carbon dioxide (ECO2), VT, and rate of carbon dioxide elimination (VCO2) to assess lung aeration in preterm infants requiring respiratory support immediately after birth. Method A prospective observational study was performed between March and July 2013. Infants born at <37 weeks gestational age who received continuous positive airway pressure (CPAP) or PPV immediately after birth had VT delivery and ECO2 continuously recorded using a sensor attached to the facemask. Results Fifty-one preterm infants (mean (SD) gestational age 29 (3) weeks and birth weight 1425 (592 g)) receiving respiratory support in the delivery room were included. Infants in the CPAP group (n = 31) had higher ECO2 values during the first 10 min after birth compared to infants receiving PPV (n = 20) (ranging between 18–30 vs. 13–18 mmHg, p<0.05, respectively). At 10 min no significant difference in ECO2 values was observed. VT was lower in the CPAP group compared to the PPV group over the first 10 min ranging between 5.2–6.6 vs. and 7.2–11.3 mL/kg (p<0.05), respectively. Conclusions Immediately after birth, spontaneously breathing preterm infants supported via CPAP achieved better lung aeration compared to infants requiring PPV. PPV guided by VT and ECO2 potentially optimize lung aeration without excessive VT administered.
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Affiliation(s)
- Liane J. Kang
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
- Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Canada
| | - Po-Yin Cheung
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
- Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Canada
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
- Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Canada
- Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Megan O’Reilly
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
- Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Canada
| | - Khalid Aziz
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
- Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Canada
| | - Georg M. Schmölzer
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
- Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Canada
- Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
- * E-mail:
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